Provider Demographics
NPI:1063606937
Name:ROGGOW, CHARLES (ATC)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:ROGGOW
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 ALEIKI PL
Mailing Address - Street 2:
Mailing Address - City:PAIA
Mailing Address - State:HI
Mailing Address - Zip Code:96779-9716
Mailing Address - Country:US
Mailing Address - Phone:808-579-8626
Mailing Address - Fax:808-579-8630
Practice Address - Street 1:270 A 'APUEO PARKWAY
Practice Address - Street 2:
Practice Address - City:PUKALANI
Practice Address - State:HI
Practice Address - Zip Code:96768
Practice Address - Country:US
Practice Address - Phone:808-573-7108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-04
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2255A2300X2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer